Association of Patient-Level and Hospital-Level Factors With Timely Fracture Care by Race
Authors: Ida Leah Gitajn, Paul Werth, Eseosa Fernandes, Sheila Sprague, Nathan N. O'Hara, Sofia Bzovsky, Lucas S. Marchand, Joseph Thomas Patterson, Christopher Lee, Gerard P. Slobogean, Gerard P Slobogean, Sheila Sprague, Jeffrey Wells, Mohit Bhandari, Anthony D Harris, C Daniel Mullins, Lehana Thabane, Amber Wood, Gregory J Della Rocca, Joan Hebden, Kyle J Jeray, Lucas S Marchand, Lyndsay M O'Hara, Robert Zura, Christopher Lee, Joseph Patterson, Michael J Gardner, Jenna Blasman, Jonah Davies, Stephen Liang, Monica Taljaard, PJ Devereaux, Gordon H Guyatt, Debra Marvel, Jana Palmer, Jeff Friedrich, Nathan N O'Hara, Ms Frances Grissom, I Leah Gitajn, Saam Morshed, Robert V O'Toole, Bradley A Petrisor, Franca Mossuto, Manjari G Joshi, Jean Claude D'Alleyrand, Justin Fowler, Jessica Rivera, Max Talbot, Shannon Dodds, Silvia Li, David Pogorzelski, Alejandra Rojas, Gina Del Fabbro, Olivia P Szasz, Diane Heels Ansdell, Paula McKay, Kevin Murphy, Andrea Howe, Haley Demyanovich, Eric Kettering, Genevieve Polk, Michelle Medeiros, Andrew Eglseder, Aaron Johnson, Christopher Langhammer, Christopher Lebrun, Jason Nascone, Raymond Pensy, Andrew Pollak, Marcus Sciadini, Yasmin Degano, Haley K Demyanovich, Heather Phipps, Eric Hempen, Brad A Petrisor, Herman Johal, Bill Ristevski, Dale Williams, Matthew Denkers, Krishan Rajaratnam, Jamal Al-Asiri, Jodi Gallant, Kaitlyn Pusztai, Sarah MacRae, Sara Renaud, Roman N Natoli, Todd O McKinley, Walter W Virkus, Anthony T Sorkin, Jan P Szatkowski, Brian H Mullis, Yohan Jang, Luke A Lopas, Lauren C Hill, Courteney L Fentz, Maricela M Diaz, Krista Brown, Katelyn M Garst, Emma W Denari, Patrick Osborn, Sarah Pierrie, Maria Herrera, John D Adams, Michael L Beckish, Christopher C Bray, Timothy R Brown, Andrew W Cross, Timothy Dew, Gregory K Faucher, Richard W Gurich, David E Lazarus, S John Millon, M Christian Moody, M Jason Palmer, Scott E Porter, Thomas M Schaller, Michael S Sridhar, John L Sanders, L Edwin Rudisill, Michael J Garitty, Andrew S Poole, Michael L Sims, Clark M Walker, Robert Carlisle, Erin A Hofer, Brandon Huggins, Michael Hunter, William Marshall, Shea B Ray, Cory Smith, Kyle M Altman, Julia C Quirion, Erin Pichiotino, Markus F Loeffler, Austin A Cole, Ethan J Maltz, Wesley Parker, T Bennett Ramsey, Alex Burnikel, Michael Colello, Russell Stewart, Jeremy Wise, Matthew Anderson, Joshua Eskew, Benjamin Judkins, James M Miller, Stephanie L Tanner, Rebecca G Snider, Christine E Townsend, Kayla H Pham, Abigail Martin, Emily Robertson, Emily Bray, Krystina Yoder, Kelsey Conner, Harper Abbott, Meir Mormor, Theodore Miclau, Amir Matityahu, R Trigg McClellan, David Shearer, Paul Toogood, Anthony Ding, Jothi Murali, Ashraf El Naga, Jennifer Tangtiphaiboontana, Tigist Belaye, Eleni Berhaneselase, Dmitry Pokhvashchey, Joshua L Gary, Stephen J Warner, John W Munz, Andrew M Choo, Timothy S Achor, Milton L "Chip" Routt, Michael Kutzler Kutzler, Sterling Boutte, Ryan J Warth, Jennifer E Hagen, Matthew Patrick, Richard Vlasak, Thomas Krupko, Michael Talerico, Marybeth Horodyski, Marissa Pazik, Elizabeth Lossada-Soto, Niloofar Dehghan, Michael McKee, Clifford B Jones, Debra L Sietsema, Alyse Williams, Tayler Dykes, Ernesto Guerra-Farfan, Jordi Thomas-Hernandez, Jordi Teixidor-Serra, Vicente Molero-Garcia, Jordi Selga-Marsa, Juan Antonio Porcel-Vazquez, Jose Vicente Andres-Peiro, Ignacio Esteban-Feliu, Nuria Vidal-Tarrason, Jordi Serracanta, Jorge Nuñez-Camarena, Maria del Mar Villar-Casares, Juame Mestre-Torres, Pilar Lalueza-Broto, Felipe Moreira-Borim, Yaiza Garcia-Sanchez, Francesc Marcano-Fernández, Laia Martínez-Carreres, David Marti-Garin, Jorge Serrano-Sanz, Joel Sánchez-Fernández, Matsuyama Sanz-Molero, Alejandro Carballo, Xavier Pelfort, Francesc Acerboni-Flores, Anna Alavedra-Massana, Neus Anglada-Torres, Alexandre Berenguer, Jaume Cámara-Cabrera, Ariadna Caparros-García, Ferran Fillat-Gomà, Ruben Fuentes-López, Ramona Garcia-Rodriguez, Nuria Gimeno-Calavia, Marta Martínez-Álvarez, Patricia Martínez-Grau, Raúl Pellejero-García, Ona Ràfols-Perramon, Juan Manuel Peñalver, Monica Salomó Domènech, Albert Soler-Cano, Aldo Velasco-Barrera, Christian Yela-Verdú, Mercedes Bueno-Ruiz, Estrella Sánchez-Palomino, Vito Andriola, Matilde Molina-Corbacho, Yeray Maldonado-Sotoca, Alfons Gasset-Teixidor, Jorge Blasco-Moreu, Núria Fernández-Poch, Josep Rodoreda-Puigdemasa, Arnau Verdaguer-Figuerola, Heber Enrique Cueva-Sevieri, Santiago Garcia-Gimenez, William T Obremsky, Amir Alex Jahangir, Manish Sethi, Robert Boyce, Daniel J Stinner, Phillip Mitchell, Karen Trochez, Elsa Rodriguez, Charles Pritchett, Natalie Hogan, A Fidel Moreno, Christina Boulton, Jason Lowe, John T Ruth, Brad Askam, Andrea Seach, Alejandro Cruz, Breanna Featherston, Robin Carlson, Iliana Romero, Isaac Zarif, Michael Prayson, Indresh Venkatarayappa, Brandon Horne, Jennifer Jerele, Linda Clark, Nicholas M Romeo, Heather A Vallier, Anna Vergon, Darius G Viskontas, Kelly L Apostle, Dory S Boyer, Farhad O Moola, Bertrand H Perey, Trevor B Stone, H Michael Lemke, Ella Spicer, Krysten Payne, Kevin Phelps, Michael Bosse, Madhav Karunakar, Laurence Kempton, Stephen Sims, Joseph Hsu, Rachel Seymour, Christine Churchill, Ada Mayfield, Juliette Sweeney, Robert A Hymes, Cary C Schwartzbach, Jeff E Schulman, A Stephen Malekzadeh, Michael A Holzman, Greg E Gaski, Johnathan Wills, Holly Pilson, Eben A Carroll, Jason J Halvorson, Sharon Babcock, J Brett Goodman, Martha B Holden, Wendy Williams, Taylor Hill, Ariel Brotherton, Thomas F Higgins, Justin M Haller, David L Rothberg, Zachary M Olsen, Abby V McGowan, Sophia Hill, Morgan K Dauk, Marcus Coe, Kevin Dwyer, Devin S Mullin, Theresa A Chockbengboun, Peter A DePalo, Marilyn Heng, Mitchel B Harris, David W Lhowe, John G Esposito, Ahmad Alnasser, Steven F Shannon, Alesha N Scott, Bobbi Clinch, Becky Webber, Michael J Beltran, Michael T Archdeacon, Henry Claude Sagi, John D Wyrick, Theodore Toan Le, Richard T Laughlin, Cameron G Thomson, Kimberly Hasselfeld, Carol A Lin, Mark S Vrahas, Charles N Moon, Milton T Little, Geoffrey S Marecek, Denice M Dubaclet, John A Scolaro, James R Learned, Philip K Lim, Susan Demas, Arya Amirhekmat, Yan Marco Dela Cruz, Patrick F Bergin, George V Russell, Matthew L Graves, John Morellato, Sheketha L McGee, Eldrin L Bhanat, Ugur Yener, Rajinder Khanna, Priyanka Nehete, Samir Mehta, Derek Donehan, Annamarie Horan, Mary Dooley, David Potter, Robert VanDemark, Kyle Seabold, Nicholas Staudenmier, Michael J Weaver, Arvind G von Keudell, Abigail E Sagona, Todd Jaeblon, Robert Beer, Brent Bauer, Sean Meredith, Sneh Talwar, Christopher M Domes, Mark J Gage, Rachel M Reilly, Ariana Paniagua, JaNell Depree
Journal: JAMA Network Open (2022)

Racial disparities in treatment benchmarks have been documented among older patients with hip fractures. However, these studies were limited to patient-level evaluations.To assess whether disparities in meeting fracture care time-to-surgery benchmarks exist at the patient level or at the hospital or institutional level using high-quality multicenter prospectively collected data; the study hypothesis was that disparities at the hospital-level reflecting structural health systems issues would be detected.This cohort study was a secondary analysis of prospectively collected data in the PREP-IT (Program of Randomized trials to Evaluate Preoperative antiseptic skin solutions in orthopaedic Trauma) program from 23 sites throughout North America. The PREP-IT trials enrolled patients from 2018 to 2021, and patients were followed for 1-year. All patients with hip and femur fractures enrolled in the PREP-IT program were included in analysis. Data were analyzed April to September 2022.Patient-level and hospital-level race, ethnicity, and insurance status.Primary outcome measure was time to surgery based on 24-hour time-to-surgery benchmarks. Multilevel multivariate regression models were used to evaluate the association of race, ethnicity, and insurance status with time to surgery. The reported odds ratios (ORs) were per 10% change in insurance coverage or racial composition at the hospital level.A total of 2565 patients with a mean (SD) age of 64.5 (20.4) years (1129 [44.0%] men; mean [SD] body mass index, 27.3 [14.9]; 83 [3.2%] Asian, 343 [13.4%] Black, 2112 [82.3%] White, 28 [1.1%] other) were included in analysis. Of these patients, 834 (32.5%) were employed and 2367 (92.2%) had insurance; 1015 (39.6%) had sustained a femur fracture, with a mean (SD) injury severity score of 10.4 (5.8). Five hundred ninety-six patients (23.2%) did not meet the 24-hour time-to-operating-room benchmark. After controlling for patient-level characteristics, there was an independent association between missing the 24-hour benchmark and hospital population insurance coverage (OR, 0.94; 95% CI, 0.89-0.98; P = .005) and the interaction term between hospital population insurance coverage and racial composition (OR, 1.03; 95% CI, 1.01-1.05; P = .03). There was no association between patient race and delay beyond 24-hour benchmarks (OR, 0.96; 95% CI, 0.72-1.29; P = .79).In this cohort study, patients who sought care from an institution with a greater proportion of patients with racial or ethnic minority status or who were uninsured were more likely to experience delays greater than the 24-hour benchmarks regardless of the individual patient race; institutions that treat a less diverse patient population appeared to be more resilient to the mix of insurance status in their patient population and were more likely to meet time-to-surgery benchmarks, regardless of patient insurance status or population-based insurance mix. While it is unsurprising that increased delays were associated with underfunded institutions, the association between institutional-level racial disparity and surgical delays implies structural health systems bias.